As I begin my overnight pediatric emergency department shift, there is one patient waiting to be seen: a six-year-old male with autism who is alleged to have experienced sexual assault. In my first year of pediatrics residency, I haven’t yet managed a sexual assault case, but it’s time for me to learn. I sign up to see the patient and move to find them in the sub-waiting room.
As I round the corner, I find a family scattered across the folding chairs attached to the walls. Mom and Dad are holding each other and crying. Another woman is supervising three children—two boys and one girl—as they play on the emergency room floor. Dad just arrived from work, and Mom is explaining what happened. However, both parents speak only Spanish. “I will come back with an interpreter,” I tell her. The patient, a 6-year-old boy with autism, is rolling a toy train back and forth with his sister. He appears stable and doesn’t seem to require urgent attention.
I return with the interpreter, and we bring the family into a private consultation room to discuss what happened. According to mom, the patient and his younger brother were being watched by their older brother, aged 17, during the day. When mom came home from work and was doing the patient’s laundry, she discovered blood on the inside of his underwear.
The language mom uses to describe why she believes this happened is somewhat unclear. I ask the interpreter to clarify. While the interpreter’s phone rings, he politely declines the call. Mom tries to explain again, but she struggles to find the words. The interpreter’s phone rings once more, and he declines the call again, this time with impatience. Mom is crying, so I offer her a tissue. The consultation room feels increasingly hot and cramped. The patient grows restless, having nothing to do in there.
We shift our questions to the patient. Nervously pushing his toy train, he speaks in staccato sentence fragments. His language is simple but clear. The events he describes can only be interpreted as a sexual assault. The parents watch nervously as I examine the patient’s genitals and external anus. Everything appears normal—no signs of damage or bleeding. The family feels relieved. I inform them that I will discuss a plan with the team.
As I step out of the room, I find myself sweating and gasping for air. The small space feels devoid of oxygen, and I experience nausea. I will have to retell the story to the attending physician, the social worker, child protective services, and the hospital’s child abuse specialist. It was difficult to hear it once, and now I must repeat it to myself for the next hour.
One by one, each relevant party listens to the story and provides their opinion. The child abuse specialist determines that we need to involve the county police to file a report and have a sexual assault nurse evaluator (SANE nurse) perform an examination. It seems like a substantial number of people to be involved, and their roles aren’t entirely clear to me. Nevertheless, they all exhibit confidence in the necessary steps, so I relay the information and move forward.
The night progresses slowly. I have seen nine patients since my shift began. Around 3 a.m., the PA system blares: “Adult code blue, attending physician to the code bay.” The patient’s father collapses to the ground, experiencing chest pain and shortness of breath. We conduct an EKG and check troponin levels. It turns out not to be a heart attack but more likely an anxiety attack. He calms down, and the symptoms resolve.
The SANE nurse arrives and performs her examination. The police come and go, filing a report but offering no further input. At 7 a.m., child protective services (CPS) arrives, marking the final consultant on my list. They speak with the family for half an hour and stop by my workstation on their way out to give me instructions. The family is cleared to leave. They have decided not to press charges against their older son, and he will not be staying at the house, ensuring the patient’s safety. CPS will conduct a home visit. The entire family has been waiting for over 10 hours.
The CPS worker appears confused as to why we called the police and performed a SANE exam. Mom explicitly told CPS that she didn’t want to press charges, making evidence collection or police involvement unnecessary. She explains that the family is undocumented and expresses anxiety because an official police report has been filed. Mom indicated that this is one reason they are so worried—they fear deportation.
The CPS representative seems to think I made a mistake. I become defensive, questioning her: “Where were these instructions last night?” “Why did the child abuse specialist instruct me to call the police?” “I merely did what I was told.” However, my arguments fail to impress her, and she leaves. I discharge the family, end my shift, and go home.
After every night shift, I have a routine of eating cereal and watching TV to decompress. As I turn on the TV, the screen displays the newly elected 45th president. It shows a clip from a speech he delivered the previous night, discussing the deportation of illegal immigrants. The footage is followed by scenes of immigration officers raiding family homes. My defensiveness dissipates, replaced by regret.
Throughout the night, I subjected that family to invasive examinations and police interviews without clear reasons. All they sought and needed was reassurance regarding their son’s well-being and guidance to ensure his safety. I allowed myself to become distracted while attempting to execute a medico-legal process I didn’t fully comprehend.
Every resident worries about making mistakes. We have nightmares about prescription errors, botched procedures, and missed diagnoses. Although my management of that family didn’t involve a classic medical error, it undoubtedly felt like a significant mistake.
The author is an anonymous physician.
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